Government Agency: United States. Department of Defense; United States. Department of Veterans Affairs

Geographic:

Geographic Scope: United States Geographic Code: 1USA United States

Accession Number:

248578904

Full Text:

Department of Veterans Affairs

Department of Defense

American Heart Association/American Stroke Association

Guideline Summary

Prepared by: THE MANAGEMENT OF STROKE REHABILITATION Working Group

With support from: The Office of Quality and Performance, VA,
Washington, DC & Quality Management Division, United States Army
MEDCOM

QUALIFYING STATEMENTS

The Department of Veterans Affairs (VA) and The Department of
Defense (DoD) guidelines are based on the best information available at
the time of publication. They are designed to provide information and
assist in decision-making. They are not intended to define a standard of
care and should not be construed as one. Also, they should not be
interpreted as prescribing an exclusive course of management. Variations
in practice will inevitably and appropriately occur when providers take
into account the needs of individual patients, available resources, and
limitations unique to an institution or type of practice. Every
healthcare professional making use of these guidelines is responsible
for evaluating the appropriateness of applying them in any particular
clinical situation.

INTRODUCTION

This update of the Clinical Practice Guideline for the Management
of Stroke Rehabilitation was developed under the auspices of the
Veterans Health Administration (VHA) and the Department of Defense (DoD)
pursuant to directives from the Department of Veterans Affairs (VA). VHA
and DoD define clinical practice guidelines as follows:

"Recommendations for the performance or exclusion of specific
procedures or services derived through a rigorous methodological
approach that includes:

* Determination of appropriate criteria, such as effectiveness,
efficacy, population benefit, or patient satisfaction and a literature
review to determine the strength of the evidence in relation to these
criteria." This VA/DoD Stroke Rehabilitation guideline update
builds on the 1996 VA Stroke/Lower Extremity Amputee Algorithms Guide
and the 2003 VA/DoD Guideline for the Management of Stroke
Rehabilitation in the Primary Care Setting. The 2003 version of this
guideline focused on stroke rehabilitation, utilizing a team model of
intervention and interactions with patients and families (caregivers
& support systems).

Algorithms:

This guideline has been developed using an algorithmic approach to
guide the clinician in determining care and the sequencing of
interventions on a patient-specific basis. The clinical algorithm
incorporates the information presented in the guideline in a format that
maximally facilitates clinical decision-making. The use of the
algorithmic format was chosen because such a format improves data
collection, facilitates diagnostic and therapeutic decision-making, and
facilitates changes in patterns of resource use. However, these
guidelines should not prevent providers from using their own clinical
expertise in the care of an individual patient. Guideline
recommendations are intended to support clinical decision-making and
should never replace sound clinical judgment.

The VA developed an algorithm for the Stroke/Lower Extremity
Amputee Algorithms Guide (1996), and the results of implementation of
this guideline demonstrated the utility of the algorithm, as well as the
feasibility of implementing a standard algorithm of rehabilitation care
in a large healthcare system (Bates & Stineman, 2000).

The algorithm of the 2003 version of the guideline was modified to
emphasize early decision-making regarding discharge to home/community.
The key decisions in early stages of the assessment and management of a
patient recovering from stroke include assessment of rehabilitation
needs and the appropriateness of providing these interventions in both
community and outpatient rehabilitation settings.

The interventions module on this 2010 update has been reorganized,
and the recommendations are formulated to address possible impairment
regardless of care setting.

Target Population:

This guideline applies to adult patients (18 years or older) with
post-stroke functional disability who may require rehabilitation in the
VHA or DoD healthcare system.

Audiences:

The guideline is relevant to all healthcare professionals providing
or directing treatment services to patients recovering from a stroke in
any healthcare setting (primary care, specialty care, and long-term
care) and in community programs.

Guideline Goals:

The most important goal of the VA/DoD Clinical Practice Guideline
for the Management of Stroke Rehabilitation is to provide a scientific
evidence-base for practice evaluations and interventions. The guideline
was developed to assist facilities to implement processes of care that
are evidence-based and designed to achieve maximum functionality and
independence, as well as improve patient and family quality of life. To
facilities lacking an organized RBU, the Guideline will provide a
structured approach to stroke care and assure that veterans who
experience a stroke will have access to comparable care regardless of
geographic location. The algorithm will serve as a guide to help
clinicians determine best interventions and timing of care for their
patients, better stratify stroke patients, reduce re-admissions, and
optimize healthcare utilization. If followed, the guideline is expected
to have a positive impact on multiple measurable patient outcome
domains.

Development Process:

The development process of this guideline follows a systematic
approach described in "Guideline-for-Guidelines," an internal
working document of the VA/DoD Evidence-Based Practice Working Group
that requires an ongoing review of the work in progress. Appendix A (see
fill guideline) clearly describes the guideline development process
followed for this guideline.

Literature searches covering the period from January 2002 through
March 2009 were conducted that combined terms for cerebrovascular
disorders and rehabilitation or rehab [title]. Adding a stroke text word
did not appear to be useful because doing so did not enhance sensitivity
and also decreased specificity. Electronic searches were supplemented by
reference lists and additional citations were suggested by experts. The
identified and selected studies on those issues were critically
analyzed, and evidence was graded using a standardized format. The
evidence rating system for this document is based on the system used by
the U.S. Preventive Services Task Force (USPSTF).

If evidence exists, the discussion following the recommendations
for each annotation includes an evidence table identifying the studies
that have been considered, the quality of the evidence, and the rating
of the strength of the recommendation (SR). The Strength of
Recommendation, based on the level of the evidence and graded using the
USPSTF rating system (see Table: Evidence Rating System), is presented
in brackets following each guideline recommendation.

Where existing literature is ambiguous or conflicting, or where
scientific data is lacking on an issue, recommendations are based on the
clinical experience of the Working Group. Although several of the
recommendations in this guideline are based on weak evidence, some of
these recommendations are strongly recommended based on the experience
and consensus of the clinical experts and researchers of the Working
Group. Recommendations that are based on consensus of the Working Group
include a discussion of the expert opinion on the given topic. No
strength of recommendation is presented for these recommendations. A
complete bibliography of the references in this guideline can be found
in Appendix E (see full guideline).

KEY POINTS

* The primary goal of rehabilitation is to prevent complications,
minimize impairments, and maximize function.

1. Effective rehabilitation improves functional outcome. An
indicator for improvement is the positive change in the Functional
Independence Measures (FIM(tm)) score over a period of time in the
post-acute care period. Within the Veterans Health Administration (VHA),
this measure is captured in the Functional Status and Outcomes Database
for rehabilitation. All stroke patients should be entered into the
database, as directed by VHA Directive 2000-016 (dated June 5, 2000;
Medical Rehabilitation Outcomes for Stroke, Traumatic Brain, and Lower
Extremity Amputee Patients).

2. Additional indicators that should be measured at three months
following the acute stroke episode may include the following:

* Functional status (including activities of daily living [ADL] and
instrumental activities of daily living [IADL])

* Rehospitalizations

* Community dwelling status

* Mortality

The primary outcome measure for assessment of functional status is
the FIMTM (UDSMR, 1997) (see Appendix B). The [FIM.sup.TM] has been
tested extensively in rehabilitation for reliability, validity, and
sensitivity, and is by far the most commonly used outcome measure. A
return to independent living requires not only the ability to perform
basic ADLs, but also the ability to carry out more complex activities
(i.e., IADLs), such as shopping, preparing meals, using of the phone,
driving a car, and managing money. These functions should be evaluated
as the patient returns to the community. New stroke-specific outcome
measures, such as the Stroke Impact Scale (Duncan et al., 2002a), may be
considered for a more comprehensive assessment of functional status and
quality of life.

ALGORITHM

[ILLUSTRATION OMITTED]

[ILLUSTRATION OMITTED]

[ILLUSTRATION OMITTED]

ANNOTATIONS

ASSESSMENT

The highest priorities of early stroke rehabilitation are to
prevent recurrence of stroke, manage comorbidities, and prevent
complications. Ensuring proper management of general health functions,
promoting mobilization, and encouraging resumption of self-care
activities, as well as providing of emotional support to the patient and
family, are important. Following the "acute" phase of stroke
care, the focus of care turns to recovery of physical and cognitive
deficits, as well as compensation for residual impairment.

Annotation A. Patient with Stroke during the Acute Phase

1 REHABILITATION DURING THE ACUTE PHASE

AHCPR (1995) defines "acute care" as the period of time
immediately following the onset of an acute stroke. Patients with an
acute stroke are typically treated in a medical service or in a
specialized stroke unit, and rehabilitation interventions normally begin
during the acute phase.

Because of the nature of the neurological problems and the
propensity for complications, most patients with acute ischemic stroke
are admitted to a hospital. A recent meta-analysis demonstrates that
outcomes can be improved if a patient is admitted to a facility that
specializes in the care of stroke. The goals of early supportive care
after admission to the hospital are to

a. Observe changes in the patient's condition that might
prompt different medical or surgical interventions.

e. Begin efforts to restore function through rehabilitation or
other techniques.

After stabilizing the patient's condition, the following can
be initiated when appropriate: rehabilitation, measures to prevent
long-term complications, chronic therapies to lessen the likelihood of
recurrent stroke, and family support (AHA, 1994).

1.1 Organization of Post-Stroke Rehabilitation Care

Over the years, the organization and delivery of stroke care has
taken many forms, and may range from minimal outpatient services to
intensive inpatient services on a specialized rehabilitation unit with
an interdisciplinary team. Because of the lack of a clear evidence base,
the types of services provided to patients with stroke are widely
variable. The Agency for Healthcare Policy and Research Guideline for
Post-Stroke Rehabilitation (AHCPR, 1995) concluded, "A considerable
body of evidence, mainly from countries in Western Europe, indicates
that better clinical outcomes are achieved when patients with acute
stroke are treated in a setting that provides coordinated,
multidisciplinary stroke-related evaluation and services. Skilled staff,
better organization of services, and earlier implementation of
rehabilitation interventions appear to be important components."
The VA/DoD Working Group reviewed the literature addressing the question
of organization of care. Although the reviews and trials make it clear
that rehabilitation is a dominant component of organized services, it is
not possible to specify precise standards and protocols for specific
types of specialized units for stroke patients. Limitations stem from
imperfections in the way the reviews and trials controlled for
differences in the structure and content of multidisciplinary/standard
care programs, the period defined as acute post-stroke care, staff
experience and staff mix, and patient needs for rehabilitation therapy
(i.e., stroke severity and type).

* High risk for aspiration: Patients who are non-cooperative;
failed the simple swallowing screening test (wet hoarse voice or
coughing are noted, or volume of water consumed is below population
norms); or have a history of swallowing problems, aspiration, or
dysphagia.

3. Patients who are not alert should be monitored closely and
swallowing screening should be performed when clinically appropriate.

4. If screening results indicate that the patient is at high risk
for dysphagia, oral food and fluids should be withheld from the patient
(i.e., the patient should be Nil per os [NPO]) and a comprehensive
clinical evaluation of swallowing food and fluids should be performed
within 24 hours by a clinician trained in the diagnosis and management
of swallowing disorders.

1.4 Use of Standardized Assessments

Annotation C. Assessment of Stroke Severity

RECOMMENDATIONS

1. Strongly recommend that the National Institutes of Health Stroke
Scale (NIHSS) be used at the time of presentation/hospital admission, or
at least within the first 24 hours following presentation. [A]

2. Recommend that all patients be screened for depression and
motor, sensory, cognitive, communication, and swallowing deficits by
appropriately trained clinicians using standardized and valid screening
tools. [C]

3. If depression or motor, sensory, cognitive, communication, or
swallowing deficits are found on initial screening assessment, patients
should be formally assessed by the appropriate clinician from the
coordinated rehabilitation team. [C]

4. Recommend that the clinician use standardized, validated
assessment instruments to evaluate the patient's stroke-related
impairments, functional status, and participation in community and
social activities. [C]

5. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care,
and develop interventions.

6. Recommend that the assessment findings be shared and the
expected outcomes discussed with the patient and family/caregivers.

Annotation D. Initiate Secondary Prevention and Early Interventions

1.5 Secondary Stroke Prevention

For specific evidence-based recommendations, providers may refer to
the AHA/ASA Guidelines for Prevention of Stroke in Patients with
Ischemic Stroke or Transient Ischemic Attack (Ralph et al., 2006).

(http://stroke.ahaj ournals.org/cgi/content/full/37/2/577)

1.6 Early Intervention of Rehabilitation Therapy

RECOMMENDATIONS

1. Strongly recommend that rehabilitation therapy start as early as
possible once medical stability is reached. [A]

2. Recommend that the patient receive as much therapy as
"needed" and tolerated to adapt, recover, and/or reestablish
the premorbid or optimal level of functional independence.

Annotation F. Obtain Medical History and Physical Examination

RECOMMENDATIONS

1. A thorough history and physical examination should be completed
on all patients and should include, at a minimum:

c. Assessment of participation in community and social activities,
and a complete psychosocial assessment (family and caregivers, social
support, financial, and cultural support) (see Annotation G: 6.1)

Annotation E. Assessment and Prevention of Complications

2 PREVENTION OF COMPLICATIONS

RECOMMENDATIONS

1. Recommend that risk of complications should be assessed in the
initial phase and throughout the rehabilitation process and followed by
intervention to address the identified risk. Areas of assessment
include:

a. Swallowing problems (risk of aspiration) (see 2.1)

b. Malnutrition and dehydration (see 2.2)

c. Skin assessment and risk for pressure ulcers (see 2.3)

d. Risk of deep vein thrombosis (DVT) (see 2.4)

e. Bowel and bladder dysfunction (see 2.5)

f. Sensation and pain (2.6)

g. Risk of falling (2.7)

h. Osteoporosis (2.8)

i. Seizures (2.9)

2.1 Swallowing Problems, Aspiration Risk

RECOMMENDATIONS

Assessment

1. Recommend all patients receive evaluation of nutrition and
hydration status as soon as possible after admission. Food and fluid
intake should be monitored daily in all patients and body weight should
be determined regularly.

2. Recommend that if screening for swallowing problems indicates
that the patient is at risk for dysphagia, the patient should be Nil per
os (NPO) and a comprehensive clinical evaluation of swallowing of food
and fluid be performed within 24 hours by a professional trained in the
diagnosis and management of swallowing disorders. Documentation of this
exam should include information about signs and symptoms of dysphagia,
likelihood of penetration and aspiration, and specific recommendations
for follow-up, including need for a dynamic instrumental assessment,
treatment, and follow-up. [I]

3. Recommend patients who are diagnosed as having dysphagia based
on comprehensive clinical evaluation of swallowing have a dynamic
instrumental evaluation to specify swallowing anatomy and physiology,
mode of nutritional intake, diet, immediate effectiveness of swallowing
compensations and rehabilitative techniques, and referral to specialist.
The optimal diagnostic procedure (VFSS, FEES) should be determined by
the clinician, based on patient needs and clinical setting.

2.2 Malnutrition and Dehydration

RECOMMENDATIONS:

1. Recommend all patients receive evaluation of nutrition and
hydration as soon as possible after admission. Food and fluid intake
should be monitored in all patients, and body weight should be
determined regularly.

2. Recommend that a variety of methods be used to maintain and
improve intake of food and fluids. This will require treating the
specific problems that interfere with intake, providing assistance in
feeding if needed, consistently offering fluid by mouth to dysphagic
patients, and catering to the patient's food preferences. If intake
is not maintained, feeding by a feeding gastrostomy may be necessary.

3. Patients at high risk for or who have problems with nutrition
and should receive counseling, along with their family/caregiver, from a
Registered Dietitian upon discharge regarding healthy diet and food
choices.

2.3 Prevention of Skin Breakdown

RECOMMENDATIONS

Assessment

1. Recommend a thorough assessment of skin integrity be completed
upon admission and monitored at least daily thereafter. [C]

2. Risk for skin breakdown should be assessed using a standardized
assessment tool (such as the Braden Scale). [I]

Treatment

3. Recommend the use of proper positioning, turning, and
transferring techniques and judicious use of barrier sprays, lubricants,
special mattresses, and protective dressings and padding to avoid skin
injury due to maceration, friction, or excessive pressure. [C]

2.4 Risk for Deep Vein Thrombosis (DVT)

RECOMMENDATIONS

Assessment

1. Concurrent risk factors that increase the risk of DVT should be
assessed in all patients post stroke to determine the choice of therapy.
These risk factors include mobility status, congestive heart failure
(CHF), obesity, prior DVT or pulmonary embolism, limb trauma, or long
bone fracture.

Treatment

2. Recommend all patients be mobilized, as soon as possible.

3. Recommend the use of subcutaneous low-dose low molecular weight
heparin (LMWH) to prevent DVT/ PE for patients with ischemic stroke or
hemorrhagic stroke and leg weakness with impaired mobility.

4. Attention to a history of heparin induced thrombocytopenia will
affect treatment choice. A platelet count obtained 7-10 days after
initiation of heparin therapy should be considered.

5. Consider the use of graduated compression stockings or an
intermittent pneumatic compression device as an adjunct to heparin for
non-ambulatory patients, or as an alternative to heparin for patients in
whom anticoagulation is contraindicated.

6. Consider IVCF is patients at risk for PE, in whom
anticoagulation is contraindicated. 2.5 Bowel and Bladder

RECOMMENDATIONS

Assessment

1. Recommend a structured assessment of bladder function in acute
stroke patients, as indicated. Assessment should include the following:

* Assessment of urinary retention through the use of a bladder
scanner or an in-and-out catheterization

* Measurement of urinary frequency, volume, and control

* Assessment for presence of dysuria.

2. There is insufficient evidence to recommend for or against the
use of urodynamics over other methods of assessing bladder function.

Treatment

3. Consider removal of the indwelling catheter within 48 hours to
avoid increased risk of urinary tract infection; however, if a catheter
is needed for a longer period, it should be removed as soon as possible.

4. Recommend the use of silver alloy-coated urinary catheters, if a
catheter is required.

5. Consider an individualized bladder training program (such as
pelvic floor muscle training in women) be developed and implemented for
patients who are incontinent of urine.

6. Recommend the use of prompted voiding in stroke patients with
urinary incontinence.

7. Recommend a bowel management program be implemented in patients
with persistent constipation or bowel incontinence. [I]

3. Recommend balancing the benefits of pain control with possible
adverse effects of medications on an individual's ability to
participate in and benefit from rehabilitation. [I]

4. When practical, utilize a behavioral health provider to address
psychological aspects of pain and to improve adherence to the pain
treatment plan. [C]

5. When appropriate, recommend use of non-pharmacologic modalities
for pain control such as biofeedback, massage, imaging therapy, and
physical therapy. [C]

6. Recommend that the clinician tailor the pain treatment to the
type of pain. [C]

7. Musculoskeletal pain syndromes can respond to correcting the
underlying condition such as reducing spasticity or preventing or
correcting joint subluxation.

8. Non-steroidal anti-inflammatory drugs (NSAIDs) may also be
useful in treating musculoskeletal pain.

9. Neuropathic pain can respond to agents that reduce the activity
of abnormally excitable peripheral or central neurons.

10. Opioids and other medications that can impair cognition should
be used with caution.

11. Recommend use of lower doses of centrally acting analgesics,
which may cause confusion and deterioration of cognitive performance and
interfere with the rehabilitation process. [C]

12. Shoulder mobility should be monitored and maintained during
rehabilitation. Subluxation can be reduced and pain decreased using
functional electrical stimulation applied to the shoulder girdle. [B]

2.7 Fall Prevention

RECOMMENDATIONS

1. Recommend that all patients be assessed for fall risk during the
inpatient phase, using an established tool. [B]

2. Recommend that fall prevention precautions be implemented for
all patients identified to be at risk for falls while they are in the
hospital.

3. Refer to the falls prevention toolkit on the National Center for
Patient Safety (NCPS) for specific interventions.

4. Recommend performing regular reassessments for risk of falling
including at discharge, ideally in the patient's discharge
environment. [B]

5. Recommend that patient and family/caregiver be provided
education on fall prevention both in the hospital setting and in the
home environment. [B]

2.8 Osteoporosis

RECOMMENDATIONS

1. Early mobilization and movement of the paretic limbs will reduce
the risk of bone fracture after stroke. [A]

2. Consider medications to reduce bone loss, which will reduce the
development of osteoporosis. [B]

3. Consider assessing bone density for patients with known
osteoporosis who have been mobilized for 4 weeks before having the
patient bear weight.

3. Insulin should be adjusted to maintain a BG < 180 mg/dl with
the goal of achieving a mean glucose around 140 mg/dl. Evidence is
lacking to support a lower limit of target blood glucose, but based on a
recent trial suggesting that blood glucose <110 mg/dl may be harmful,
we do not recommend blood glucose levels <110 mg/dl. [A]

4. Insulin therapy should be guided by local protocols, preferably
"dynamic" protocols that account for varied and changing
insulin requirements. A nurse-driven protocol for the treatment of
hypoglycemia is highly recommended to ensure prompt and effective
correction of hypoglycemia. [I]

5. To minimize the risk of hypoglycemia and severe hyperglycemia
after discharge it is reasonable to provide hospitalized patients who
have DM and knowledge deficits, or patients with newly discovered
hyperglycemia, basic education in "survival skills." [I]

6. Patients who experienced hyperglycemia during hospitalization
but who are not known to have DM should be re-evaluated for DM after
recovery and discharge. [B]

3. Management of heart disease and cardiac rehabilitation should
follow AHA, VA/DoD, and

AHCPR guidelines.

3.3 Hypertension

RECOMMENDATIONS

1. Blood pressure should be carefully monitored following stroke.

2. The type of stroke (ischemic, hemorrhagic, aneurismal), the
clinical situation, and co-morbidities must be considered in blood
pressure management. (See VA/DoD CPG for Management of Hypertension)

3.4 Substance Use Disorders (SUD)

RECOMMENDATIONS

1. People who have survived a stroke should be educated about the
risks associated with excessive alcohol usage, substance abuse, and the
risk for stroke recurrence.

2. Patients who are smokers should be counseled about the benefits
of smoking cessation on reducing the risk for a future stroke, and they
should be considered for nicotine replacement therapy and other
interventions that promote smoking cessation.

3.5 Post Stroke Depression

RECOMMENDATIONS

1. There are several treatment options for the patient with stroke
and mild depression that can be used alone or in combination based on
the patient's individual need and preference for services. Refer to
VA/DoD guidelines for the management of Major Depression Disorder (MDD).

2. Patients diagnosed with moderate to severe depression after
stroke should be referred to Mental Health specialty for evaluation and
treatment.

3. There is conflicting evidence regarding the use of routine
pharmacotherapy or psychotherapy to prevent depression or other mood
disorders following stroke.

4. Patients with stroke who are suspected of wishing to harm
themselves or others (suicidal or homicidal ideation) should be referred
immediately to Mental Health for evaluation.

5. Recommend that patients with stroke should be given information,
advice, and the opportunity to talk about the impact of the illness upon
their lives.

Other Mood Disorders

6. Patients exhibiting extreme emotional lability following stroke
(i.e., pathological crying/tearfulness) should be given a trial of
antidepressant medication if no contraindication exists. SSRIs are
recommended in this patient population. [A]

7. Patients with stroke who are diagnosed with anxiety-related
disorders should be evaluated for pharmacotherapy options. Consider
psychotherapy intervention for anxiety and panic. Cognitive Behavioral
Therapy has been found to be a more efficacious treatment for anxiety
and panic disorder than other therapeutic interventions.

9. Encourage the patient with stroke to become involved in physical
and/or other leisure activities.

4 ASSESSMENT OF IMPAIRMENTS

Annotation G. Determine Nature and Extent of Impairments and
Disabilities

4.1 Global Assessment of Stroke Severity

RECOMMENDATIONS

1. Strongly recommend the patient be assessed for stroke severity
using the NIHSS at the time of presentation/hospital admission, or at
least within the first 24 hours following presentation. [A]

2. Strongly recommend that all professionals involved in any aspect
of the stroke care be trained and certified to perform the NIHSS. [A]

3. Consider reassessing severity using the NIHSS at the time of
acute care discharge to validate the first assessment or identify
neurological changes.

4. If the patient is transferred to rehabilitation and there are no
NIHSS scores in the record, the rehabilitation team should complete an
NIHSS.

4.2 Assessment of Communication Impairment

RECOMMENDATIONS

1. Assessment of communication ability should address the following
areas: listening, speaking, reading, writing, gesturing, and pragmatics.
Problems in communication can be language-based (as with aphasia),
sensory/motor based (as with dysarthria), or cognitive-based (as with
dementia).

2. Assessment should include standardized testing and procedures.
[B]

4.3 Assessment of Motor Impairment and Mobility

RECOMMENDATIONS

Motor Assessment

1. Motor function should be assessed at the impairment level
(ability to move in a coordinated manner in designated patterns) and at
the activity level (performance in real life or simulated real life
tasks) using assessments with established psychometric properties.

2. The following components should be considered in assessment of
motor function: muscle strength for all muscle groups, active and
passive range of motion available, muscle tone, ability to isolate the
movements of one joint from another, gross and fine motor coordination.

3. The daily use of paretic extremity should be assessed using a
self-report measure (e.g., the Motor Activity Log) and with
accelerometry.

5. Apraxia should be assessed using an established apraxia measure
(e.g., Florida Apraxia Screen). Mobility

6. Stroke survivors with impaired mobility should be referred to a
mobility-training program (physical therapy and/or occupational therapy)
where specific and individualized goals can be established.

4.4 Assessment of Cognitive Function

RECOMMENDATIONS

1. Assessment of arousal, cognition, and attention should address
the following areas:

a. Arousal

b. Attention deficits

c. Visual neglect

d. Learning and Memory deficits

e. Executive function and problem-solving difficulties

2. There is insufficient evidence to recommend the use of any
specific tools to assess cognition. Several screening and assessment
tools exist. (See Appendix B for standard screening instruments for
cognitive assessment.)

4.5 Assessment of Sensory Impairment: Touch, Vision and Hearing

RECOMMENDATIONS

1. Recommend that all patients be screened for sensory deficits by
appropriately trained clinicians. This assessment should include an
evaluation of sharp/dull, temperature, light touch, vibratory, and
position sensation.

3. Recommend that all individuals with stroke should have a vision
exam that includes visual acuity, contrast sensitivity (using Pelli
chart), perimetry for visual field integrity, eye movements (including
diplopia), and visual scanning.

4. Recommend that a careful history related to hearing impairment
be elicited from the patient and or family and that a hearing evaluation
be completed for patients who demonstrate difficulty with communication
where hearing impairment is suspected.

4.6 Assessment of Emotional and Behavioral State

RECOMMENDATIONS

1. Initial evaluation of the patient should include a psychosocial
history that covers pre-morbid personality characteristics,
psychological disorders, pre-morbid social roles, and level of available
social support.

2. Brief, continual assessments of psychological adjustment should
be conducted to quickly identify when new problems occur. These
assessments should also include ongoing monitoring of suicidal ideation
and substance abuse. Other psychological factors deserving attention
include: level of insight, level of self-efficacy/locus of control, loss
of identity concerns, social support, sexuality, and sleep.

3. Review all medications and supplements including over the
counter (OTC) medications that may affect behavior and function.

4. Inclusion of collateral information (e.g. spouse, children) is
recommended to obtain a comprehensive picture of the patient's
pre-morbid functioning and psychological changes since the stroke.

5. There is insufficient evidence to recommend the use of any
specific tools to assess psychological adjustment. Several screening and
assessment tools exist. (See Appendix B for standard instruments for
psychological assessment.)

6. Post-stroke patients should be assessed for other psychiatric
illnesses, including anxiety, bipolar illness, SUD, and nicotine
dependence. Refer for further evaluation by mental health if indicated.

5 ASSESSMENT OF ACTIVITY AND FUNCTION

5.1 ADL, IADL

RECOMMENDATIONS

1. Recommend that a standardized assessment tool be used to assess
functional status (ADL/IADL) of stroke patients. [B]

2. Consider the use of the Functional Independence Measure
([FIM.sup.TM]) as the standardized functional assessment. (See Appendix
B--Functional Independence Measure [[FIM.sup.TM]] Instrument, and a list
of other standard instruments for assessment of function and impact of
stroke)

6 ASSESSMENT OF SUPPORT SYSTEMS

6.1 Patient, Family Support, and Community Resources

RECOMMENDATIONS

1. Recommend all stroke patients and family caregivers receive a
thorough psychosocial assessment with psychosocial intervention and
referrals as needed.

2. The psychosocial assessment of both the patient with stroke and
the primary family caregiver should include the following areas:

a. History of pre-stroke functioning of both the patient and the
primary family caregiver (e.g., demographic information; past physical
conditions and response to treatment; substance use and abuse;
psychiatric, emotional, and mental status and history; education and
employment; military, legal, and coping strategies)

b. Capabilities and caregiving experiences of the person identified
as the primary caregiver

c. Caregiver understanding of the patient's needs for
assistance and caregiver's ability to meet those needs

d. Family dynamics and relationships

e. Availability, proximity, and anticipated involvement of other
family members

f. Resources (e.g., income and benefits, housing, and social
network)

g. Spiritual and cultural activities

h. Leisure time and preferred activities

i. Patient/family/caregiver understanding of the condition,
treatment, and prognosis, as well as hopes and expectations for recovery

3. Recommend a home assessment for all patients who will be
discharged home with functional impairments.

Annotation H. Does the Patient have a Severe Stroke and/or Maximum
Dependence and Poor Prognosis for Functional Recovery?

RECOMMENDATIONS

1. Families and caregivers should be educated in the care of
patients who have experienced a severe stroke, who are maximally
dependent in ADL, or have a poor prognosis for functional recovery
because these patients are not candidates for rehabilitation
intervention.

2. Families should receive counseling on the benefits of nursing
home placement for long-term care.

7 THE REHABILITATION PROGRAM

Annotation I. Does the Patient Need Rehabilitation Intervention?

7.1 Determine Rehabilitation Needs

RECOMMENDATIONS

1. Once the patient is medically stable, the primary physician
should consult with rehabilitation services (i.e., physical therapy,
occupational therapy, speech and language pathology, kinesiotherapy, and
Physical Medicine) to assess the patient's impairments, as well as
activity and participation deficiencies to establish the patient's
rehabilitation needs and goals.

2. A multidisciplinary assessment should be undertaken and
documented for all patients. [A]

3. Patients with no residual disability post acute stroke who do
not need rehabilitation services may be discharged back to home.

4. Strongly recommend that patients with mild to moderate
disability in need of rehabilitation services have access to a setting
with a coordinated and organized rehabilitation care team that is
experienced in providing stroke services. [A]

5. Post-acute stroke care should be delivered in a setting where
rehabilitation care is formally coordinated and organized.

6. If an organized rehabilitation team is not available in the
facility, patients with moderate or severe disability should be offered
a referral to a facility with such a team. Alternately, a physician or
rehabilitation specialist with some experience in stroke should be
involved in the patient's care.

7. Post-acute stroke care should be delivered by a variety of
treatment disciplines experienced in providing post-stroke care to
ensure consistency and reduce the risk of complications.

9. Patients who are severely disabled and for whom prognosis for
recovery is poor may not benefit from rehabilitation services and may be
discharged to home or nursing home in coordination with family/care
giver.

1. The medical team, including the patient and family, must analyze
the patient's medical and functional status, as well as expected
prognosis to establish the most appropriate rehabilitation setting. [I]

2. The severity of the patient's impairment, the
rehabilitation needs, the availability of family/social support and
resources, the patient/family goals and preferences, and the
availability of community resources will determine the optimal
environment for care. [I]

3. Where comprehensive interdisciplinary community rehabilitation
services and caregiver support services are available, early supported
discharge services may be provided for people with mild to moderate
disability. [B]

4. Recommend that patients remain in an inpatient setting for their
rehabilitation care if they are in need of daily professional nursing
services, intensive physician care, and/or multiple therapeutic
interventions.

5. There is insufficient evidence to recommend the superiority of
one type of rehabilitation setting over another.

6. Patients should receive as much therapy as they are able to
tolerate in order to adapt, recover, and/or reestablish their premorbid
or optimal level of functional independence. [B]

Annotation K. Discharge Patient from Rehabilitation

See Section 8 -Discharge

Annotation L. Arrange For Medical Follow-Up

See Section 8.1 - Follow-up

Annotation M. Post-Stroke Patient in Inpatient Rehabilitation

Inpatient rehabilitation is defined as rehabilitation performed
during an inpatient stay in a free-standing rehabilitation hospital or a
rehabilitation unit of an acute care hospital. The term
"inpatient" is also used to refer generically to programs
where the patient is in residence during treatment, whether in an acute
care hospital, a rehabilitation hospital, or a nursing facility.

Patients typically require continued inpatient services if they
have significant functional deficits and medical and/or nursing needs
that requires close medical supervision and 24-hour availability of
nursing care. Inpatient care may be appropriate if the patient requires
treatment by multiple other rehabilitation professionals (e.g, physical
therapists, occupational therapists, speech language pathologists, and
psychologists).

1. Patients and/or their family members should be educated in order
to make informed decisions and become good advocates.

2. The patient/family member's learning style must be assessed
(through questioning or observation) and supplemental materials
(including handouts) must be available when appropriate.

3. The following list includes topics that (at a minimum) must be
addressed during a patient's rehabilitation program:

a. Etiology of stroke

b. Patient's diagnosis and any complications/co-morbidities

c. Prognosis

d. What to expect during recovery and rehabilitation

e. Secondary prevention

f. Discharge plan

g. Follow-up care including medications.

4. The clinical team and family/caregiver should reach a shared
decision regarding the rehabilitation program.

5. The rehabilitation program should be guided by specific goals
developed in consensus with the patient, family, and rehabilitation
team.

6. Document the detailed treatment plan in the patient's
record to provide integrated rehabilitation care.

7. The patient's family/caregiver should participate in the
rehabilitation sessions, and should be trained to assist patient with
functional activities, when needed.

8. As patients progress, additional important educational topics
include subjects such as the resumption of driving, sexual activity,
adjustment and adaptation to disability, patient
rights/responsibilities, and support group information.

The treatment plan should include documentation of the following:

* Patient's strengths, impairments, and current level of
functioning

* Psychosocial resources and needs, including caregiver capacity
and availability.

1. Patients should be re-evaluated intermittently during their
rehabilitation progress. Particular attention should be paid to interval
change and progress towards stated goals.

2. Patients who show a decline in functional status may no longer
be candidates for rehabilitation interventions. Considerations about the
etiology of the decline and its prognosis can help guide decisions about
when/if further rehabilitation evaluation should occur.

3. Psychosocial status and community integration needs should be
re-assessed, particularly for patients who have experienced a functional
decline or reached a plateau.

Annotation Q. Is Patient Ready for Community Living?

7.6 Transfer to Community Living

RECOMMENDATIONS

1. Recommend that all patients planning to return to independent
community living should be assessed for mobility, ADL, and IADL prior to
discharge (including a community skills evaluation and home assessment).

2. Recommend that the patient, family, and caregivers are fully
informed about, prepared for, and involved in all aspects of healthcare
and safety needs. [I]

3. Recommend that case management be put in place for complex
patient and family situations. [I]

4. Recommend that acute care hospitals and rehabilitation
facilities maintain up-to-date inventories of community resources,
provide this information to stroke patients and their families and
caregivers, and offer assistance in obtaining needed services. Patients
should be given information about, and offered contact with, appropriate
local statutory and voluntary agencies. [I]

7.7 Function/Social Support

RECOMMENDATIONS

1. Patients and family caregivers should have their individual
psychosocial and support needs reviewed on a regular basis
post-discharge.

2. Referrals to family counseling should be offered. Counseling
should focus on psychosocial and emotional issues and role adjustment.

3. Caregivers should be screened for high levels of burden and
counseled in problem solving and adaptation skills as needed.

4. Caregivers and patients should be screened for depressive
symptoms and referred to appropriate treatment resources as needed.

5. Health and social services professionals should ensure that
patients and their families have information about the community
resources available specific to these needs.

6. Provide advocacy and outreach to patients and families living in
the community to help them adapt to changes and access community
resources.

7.8 Recreational and leisure Activity

1. Recommend that leisure activities should be identified and
encouraged and the patient enabled to participate in these activities.
[I]

2. Therapy for individuals with stroke should include the
development of problem solving skills for overcoming the barriers to
engagement in physical activity and leisure pursuits.

3. Individuals with stroke and their caregivers should be provided
with a list of resources for engaging in aerobic and leisure activities
in the community prior to discharge

4. Recommend that the patient participates in a regular
strengthening and aerobic exercise program at home or in an appropriate
community program that is designed with consideration of the
patient's co-morbidities and functional limitations. (See
Intervention - Physical Activity) [B]

7.9 Return to Work

RECOMMENDATIONS

1. Recommend that all patients, if interested and their condition
permits, be evaluated for the potential of returning to work. [C]

2. Recommend that all patients who were previously employed be
referred to vocational counseling for assistance in returning to work.
[C]

3. Recommend that all patients who are considering a return to work
but who may have psychosocial barriers (e.g. motivation, emotional, and
psychological concerns) be referred for supportive services, such as
vocational counseling or psychological services. [C]

7.10 Return to Driving

RECOMMENDATIONS

1. Recommend all patients be given a clinical assessment of their
physical, cognitive, and behavioral functions to determine their
readiness to resume driving. In individual cases, where concerns are
identified by the family or medical staff, the patient should be
required to pass the state road test as administered by the licensing
department. Each medical facility should be familiar with their state
laws regarding driving after a stroke. [I]

2. Consider referring patients with residual deficits to adaptive
driving instruction programs to minimize the deficits, eliminate safety
concerns, and optimize the chances that the patient will be able to pass
the state driving test. [I]

7.11 Sexual Function

RECOMMENDATIONS

1. Sexual issues should be discussed during rehabilitation and
addressed again after transition to the community when the post-stroke
patient and partner are ready.

Annotation R. Address Adherence to Treatments and Barriers to
Improvement:

If Medically Unstable, Refer to Acute Services

If There Are Mental Health Factors, Refer to Mental Health Services

RECOMMENDATIONS

1. When an encountered barrier, such as a medical illness, makes
participation difficult, referral to the appropriate service for
treatment is warranted.

2. When the issue is related to mental health factors, assessment
of these factors by a psychiatrist/psychologist and
intervention/treatment is appropriate.

8 DISCHARGE FROM REHABILITATION

Annotation K. Discharge Patient from Rehabilitation

RECOMMENDATIONS

1. Recommend that the rehabilitation team ensure that a discharge
plan is complete for the patient's continued medical and functional
needs prior to discharge from rehabilitation services.

2. Recommend that every patient participate in a secondary
prevention program (see Annotation D). [A]

3. Recommend post-acute stroke patients be followed by a primary
care provider to address stroke risk factors and continue treatment of
co-morbidities.

4. Recommend patient and family are educated regarding pertinent
risk factors for stroke.

5. Recommend that the family and caregivers receive all necessary
equipment and training prior to discharge from rehabilitation services.
[I]

6. Family counseling focusing on psychosocial and emotional issues
and role adjustment should be encouraged and made available to patients
and their family members upon discharge.

Annotation L. Arrange For Medical Follow-Up

8.1 Long-Term Management

RECOMMENDATIONS

1. Recommend post-discharge telephone follow-up with patients and
caregivers be initiated and include problem solving and educational
information.

2. If available, asynchronous and real-time tele-health, video, and
web-based technologies, (e.g., web-based support groups,
tele-rehabilitation), should be considered for patients who are unable
to travel into the facility for care and services.

Follow-up

3. Ongoing monitoring of anticoagulant or antiplatelet therapy,
treatment of hypertension and hypercholesterolemia, and other secondary
prevention strategies are lifelong needs of patients after stroke and
should normally be performed by the patient's primary healthcare
provider.

4. Recommend post-acute stroke patients be followed up by a primary
care provider to address stroke risk factors and continue treatment of
co-morbidities.

5. Patient and family should be educated regarding pertinent risk
factors for stroke.

6. Provide patient information about and access to community based
resources.

REHABILITATION INTERVENTION

This section includes recommendations for intervention and
treatment that address possible impairments in patients recovering from
stroke. In general, patients should receive the intensity and duration
of clinically relevant therapy defined in their individualized
rehabilitation plan and appropriate to their needs and tolerance levels.
All patients with stroke should begin rehabilitation therapy as early as
possible once medical stability is reached. The rehabilitation
interventions described in this section should apply regardless of the
specific rehabilitation setting and may be applicable during inpatient
as well as after discharge and follow-up in community outpatient
rehabilitation.

9 DYSPHAGIA MANAGEMENT

RECOMMENDATIONS

1. An oral care protocol should be implemented for patients with
dysphagia and dentures to promote oral health and patient comfort.

2. Patients with persistent dysphagia should be offered an
individualized treatment program guided by a dynamic instrumental
swallowing assessment. The treatment program may include the following:

a. Modification of food texture and fluids to address swallowing on
an individual basis.

b. Education regarding swallowing postures and maneuvers on an
individual basis following instrumental assessment to verify the
treatment effect.

c. Addressing appropriate method of medication administration for
patients with evidence of pill dysphagia on clinical or instrumental
assessment.

d. Training patients and caregivers in feeding techniques and the
use of thickening agents.

e. Patients with chronic oropharyngeal dysphagia should be seen for
regular reassessment to ensure effectiveness and appropriateness of
long-standing diet, continued need for compensations, and/or
modification of rehabilitative techniques.

10 NUTRITION MANAGEMENT

RECOMMENDATIONS

1. The nutritional and hydration status of stroke patients should
be assessed within the first 48 hours of admission.

2. Stroke patients with suspected nutritional and/or hydration
deficits, including dysphagia, should be referred to a dietitian.

3. Consider the use of feeding tubes to prevent or reverse the
effects of malnutrition in patients who are unable to safely eat and
those who may be unwilling to eat.

4. Oral supplementation may be considered for patients who are safe
with oral intake but do not receive sufficient quantities to meet their
nutritional requirements.

11 COGNITIVE REHABILITATION

11.1 Non-Drug Therapies for Cognitive Impairment

RECOMMENDATIONS

1. Recommend that patients be given cognitive re-training if any of
the following conditions are present:

a. Attention deficits [A]

b. Visual neglect [B]

c. Memory deficits [B]

d. Executive function and problem-solving difficulties [C]

2. Patients with multiple areas of cognitive impairment may benefit
from a variety of cognitive retraining approaches that may involve
multiple disciplines. [C]

3. Recommend the use of training to develop compensatory strategies
for memory deficits in post-stroke patients who have mild short term
memory deficits. [B]

11.2 Use of Drugs to Improve Cognitive Impairment

RECOMMENDATIONS

1. Consider using acetylcholinesterase inhibitors (AChEIs),
specifically galantamine, donepezil, and rivastigmine, in patients with
vascular dementia or vascular cognitive impairment in the doses and
frequency used for Alzheimer's disease.

3. The use of conventional or atypical antipsychotics for
dementia-related psychosis or behavioral disturbance should be used with
caution for short term, acute changes.

4. Recommend against centrally acting a2-adrenergic receptor
agonists (such as clonidine and others) and a1-receptor antagonists
(such as prazosin and others) as antihypertensive medications for stroke
patients because of their potential to impair recovery. [D]

5. Recommend against the use of amphetamines to enhance motor
recovery following stroke. [D]

11.3 Apraxia

RECOMMENDATIONS

1. There is insufficient evidence to support specific therapeutic
interventions for apraxia following stroke. [I]

2. Nursing and therapy sessions (e.g., for shoulder pain, postural
control, feeding) need to be modified to cue attention to the impaired
side in patient with impaired spatial awareness. [I]

12 COMMUNICATION

1. If the communication assessment indicates impairment in speech,
language, and/or cognition, treatment should be considered for those
affected components. Treatment can be provided individually, in groups,
or by computer or trained volunteer under the supervision of a
clinician.

2. Maximum restoration of the impaired ability should initially be
considered:

* For dysarthria (and other impairments of speech), treatment can
include techniques to improve articulation, phonation, fluency,
resonance, and/or respiration.

* For aphasia (and other impairments of language), treatment can
include models designed to improve comprehension (e.g.,
stimulation/facilitation) and/or expression (e.g., word retrieval
strategies) of language. It is recommended that the rate of treatment
("intensity", "dosage") should be higher rather than
lower.

* For dementia (and other impairments of cognitive aspects of
communication), treatment can include techniques to maximize attention,
memory, problem-solving, and executive functions.

3. Once maximum restoration is achieved, compensation of the
remaining impairment should be considered:

* For dementia, compensatory approaches include memory books,
portable alarms, Personal Digital Assistants (PDAs), and similar devices
to provide reminders and other information as needed.

4. Once maximum restoration and maximum benefits of compensation
are achieved, counsel and educate those closest to the patient to modify
the patient's environment to minimize and eliminate obstacles to
communication, assisting them in such activities as helping pay bills or
recording a message on their phone answering machine instructing callers
to leave a message.

13 MOTOR IMPAIRMENT AND RECOVERY

13.1 Treatment Approach

RECOMMENDATIONS

1. Strongly recommend a comprehensive motor recovery program early
on in stroke rehabilitation.

2. There is insufficient evidence to recommend for or against using
NDT in comparison to other treatment approaches for motor retraining
following an acute stroke. [I]

2. Consider use of oral agents such as tizanidine and oral baclofen
for spasticity, especially if the spasticity is associated with pain,
poor skin hygiene, or decreased function. Tizanidine should be used
specifically for chronic stroke patients. [B]

3. Diazepam and other benzodiazepines should be avoided during the
stroke recovery period because this class of medication may interfere
with cerebral functions associated with recovery of function after
stroke, and these agents are likely to produce sedation that will
compromise an individual's ability to participate effectively in
rehabilitation. [D]

4. Consider use of botulinum toxin on its own or in conjunction
with oral medication for patients with spasticity that is painful,
impairs function, reduces the ability to participate in rehabilitation,
or compromises proper positioning or skin care. [B]

5. Intrathecal baclofen treatments may be considered for stroke
patients with chronic lower extremity spasticity that cannot be
effectively managed by oral medication or botulinum toxin. [B]

1. Consider using treadmill training in conjunction with other
task-specific practice and exercise training techniques in individuals
with gait impairments post-stroke without known cardiac risks for
treadmill exercise. [B]

2. Consider the use of partial bodyweight support for treadmill
training (partial BWSTT) (up to 40% of individuals' weight) in
conjunction with other task specific and exercise training techniques
for individuals with gait impairments post stroke without known cardiac
risks for treadmill exercise. [B]

4. Recommend Functional electrical stimulation (FES) as an
adjunctive treatment for patients with impaired muscle contraction,
specifically for patients with impaired gait due to ankle/knee motor
impairment. FES can be utilized for individuals with acute or chronic
deficits after stroke. [B]

12. Do NOT use repetitive practice of movements in rehabilitation
of upper extremity.

13.7 Cardiovascular Conditioning and Fitness

RECOMMENDATIONS

1. Strongly recommend that patients participate in a regular
aerobic exercise program at home or in an appropriate community program
that is designed with consideration of the patient's comorbidities
and functional limitations. [A]

1. Recommend adaptive devices be used for safety and function if
other methods of performing the task are not available or cannot be
learned, or if the patient's safety is a concern. [C]

2. Recommend lower extremity orthotic devices be considered if
ankle or knee stabilization is needed to improve the patient's gait
and prevent falls. [C]

3. Recommend that a prefabricated brace be used initially and only
patients who demonstrate long-term need for bracing have customized
orthoses made. [C]

4. Recommend wheelchair prescriptions be based on careful
assessment of the patient and the environment in which the wheelchair
will be used. [C]

5. Recommend walking assistive devices be used to help with
mobility efficiency and safety when needed. [C]

14 SENSORY IMPAIRMENT

14.1 Sensory Impairment - Touch

RECOMMENDATIONS

1. Consider that all patients with sensory impairments be provided
sensory-specific training.

2. Consider that patients with sensory impairments be provided a
trial of cutaneous electrical stimulation in conjunction with
conventional therapy when appropriate.

14.2 Sensory impairment - Vision (Seeing)

RECOMMENDATIONS

1. Patients who have visual field cuts/hemianopsia or eye motility
impairments after stroke should be provided with an intervention program
for that visual impairment or with compensatory strategies. [I]

1. Patients and caregivers should be educated throughout the
rehabilitation process to address patient's rehabilitation needs,
expected outcomes, procedures, and treatment, as well as appropriate
follow-up in the home/community. [B]

2. Patient and caregiver education should be provided in both
interactive and written formats. [B]

3. Caregivers should be provided in a variety of methods of
training based on patients' specific needs, cognitive capability,
and local resources. Training may be provided in individual or group
format, and in community-based programs. [B]